Can we improve the existing management of pain after cesarean delivery at Eastern Regional Referral Hospital? A retrospective survey

doi:10.21203/rs.3.rs-4699965/v1

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Research Article

Can we improve the existing management of pain after cesarean delivery at Eastern Regional Referral Hospital? A retrospective survey

https://doi.org/10.21203/rs.3.rs-4699965/v1

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Background

Pain after surgery is generally considered undertreated worldwide. This may be because of resource and skill constraints. Inadequate management of pain after cesarean delivery (CD), can adversely affect the well-being of both mothers and newborns, potentially leading to a higher incidence of chronic post-operative pain. We must therefore constantly improve the quality of pain care for CDs. This study aimed to review the existing management of pain associated with CD at Eastern Regional Referral Hospital (ERRH)

Methods

This retrospective review of the management of pain after CDs, was conducted between December 2017 and December 2018 at ERRH, Bhutan. A total of 107 CD patients were reviewed.

Results

Of the 107 patients with CDs reviewed, only 2% received analgesics before surgery, and 20% received analgesics during surgery. The majority of the patients (63%) received a single injection of Diclofenac sodium, followed by oral Ibuprofen (56%) on the following day.

Conclusions

Despite the availability of resources and skills, the present review revealed that the existing management strategy of pain after CDs at ERRH was mostly a single-drug therapy, with focus mainly on the post-operative period.

Analgesics

Bhutan

Cesarean Delivery

Diclofenac

Pain Management

In 1996, the American Pain Society instituted pain as the fifth vital sign (1) and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) also introduced the assessment and management of pain as healthcare standard (2). CD is the most common type of surgery performed on pregnant women. For instance, in the U.S.A., the rate of CD exceeds 32% (3, 4). Likewise, in the U.K., 31.90% of pregnant women undergo CD (5). However, annually, approximately 800 patients are admitted to the Department of Obstetrics and Gynecology at ERRH for a cesarean rate of 34.40% (6). Among the many post-surgery pain, pain after CD is given special consideration because it is associated with the well-being of both the mother and the child (7). Pregnant women undergoing CD fear that pain might impair their early recovery (8) and care of their newborns (9). This pain can delay ambulation and cause post-partum depression and chronic pain (9). One of the main causes of poor patient’s satisfaction (10) in her childbirth experience is inadequate analgesia after CD.

Although all physicians in Bhutan have concerns about the management of pain for women undergoing CDs, to the authors’ knowledge, no one has, so far, reviewed the existing management of pain during CDs. Often, existing practices across hospitals in Bhutan follow outdated traditional methods that require immediate review and updates. Unlike other countries, Bhutan still does not have proper pain management guideline or protocol for CD. The choice of analgesics, thus the modality, solely rests on each treating physician. Some physicians prefer to use opioids, whereas others prefer either non-steroidal anti-inflammatory drugs (NSAIDs) or Paracetamol. Some physicians prefer injectables over oral analgesics and vice versa. Others may even administer a low dose of morphine intrathecally. Moreover, very few practitioners have combined systemic drugs with regional blocks. Therefore, there is no standard management protocol for pain after CDs. The literatures provides many modalities of pain management for CD (3), which are currently in practice worldwide. Most of the current literature advocates multi-modal analgesia as the best modality. In our setup, however, only a few prescribers followed the principles of multi-modal analgesia approach. According to routine observation, a vast majority of CDs in our hospital are given a single drug or, at most, two classes of drugs. Therefore, inadequate management of pain during CD rarely occurs because of the unavailability of resources and skills but often because of the poor choices that physicians make for patients. This misunderstanding is even more prevalent in reference to which surgery phase the analgesic should be administered to the patient. Mostly, pain after surgery is the only time pain is treated. The pre-operative and operative phases are unaccounted for in the management of pain. Therefore, to clearly understand, the authors reviewed the current management of pain associated with CDs, and identified gaps to improve the management of pain after CD at ERRH.

This was a retrospective review of peri-operative analgesia for patients who underwent CD at ERRH. Using a simple randomization technique, we considered 107 patients from total of 360, as detailed in Fig #1. The inclusion criterion was that all CDs were performed under spinal anesthesia between December 2017 and December 2018.

The primary objective of the survey was to review the existing management of pain in patients who underwent CDs at ERRH. We collected patients’ basic socio-demographics. The study also reviewed the data on the availability of various analgesics as per the Essential Drug List at the Department of Pharmacy, which records the status of all drugs in the hospital. We maintained the confidentiality of all the data collected from the medical records. In this retrospective review, only descriptive statistical tools were employed. The means and medians were used for all continuous variables, and percentages were used for all categorical variables.

Figure # 1.

Flow chart showing the recruitment process for patients in the study

We analyzed a total of 107 CDs that were admitted to the ERRH between December 2017 and December 2018. Their mean age was 28 years, with a minimum age of 14 years and a maximum age of 42 years. In our study, we noted that only 2% of CDs had received pre-operative analgesia. Once inside the operating room, only 20% of patients were given intra-operative analgesia. Injectable Paracetamol was the preferred choice for intra-operative analgesia.

As shown in Table # 1, for an immediate post-operative period in the ward, the most common mode of analgesia was a single injection of Diclofenac sodium (63%), followed by a combination of Diclofenac sodium and Pethidine (11%).

Table # 1

Physician’s Choice of Injectable Analgesic Used at the Ward for Immediate Post-operative Period after CD

Name of analgesic	Number of patients (Percentage)	(95% CI)
Diclofenac sodium	62 (63)	(53–72)
Pethidine	9(9)	(5–16)
Diclofenac sodium & Paracetamol	10(10)	(6–18)
Diclofenac sodium & Pethidine	11(11)	(6–19)
Diclofenac sodium & Tramadol	1(1)	(0–6)
Any other combinations	6(6)	(3–13)
Total	99 (100)

Among oral analgesics, which were mostly given on postoperative day 1, the most common choice was the single drug Ibuprofen (56%), followed by the combination of Ibuprofen and Paracetamol (29%). On the day of discharge from the hospital, patients were sent home with either oral Paracetamol (35%) or Ibuprofen (57%). The study also revealed that 9% of patients were discharged without any kind of oral analgesic (Table # 2). The patients were discharged from the hospital with the average length of oral analgesics of 3.36 days. On the availability of analgesics, we found that morphine and fentanyl were not available for 17% of patients. However, all other group of analgesics were available for all patients throughout the study duration.

Table # 2

Physician’s Choice of Oral Analgesic Used at Home for Post-operative Pain After CD

Name of oral analgesic	Number of patients (Percentage)	(95% CI)
Paracetamol	36 (35)	(26–44)
Ibuprofen	59 (57)	(47–66)
Not given any analgesic	9 (9)	(5–16)
Total	104 (100)

Globally, maternal wellbeing and childbirth are the top priorities of physicians managing CDs. Even in Bhutan, undoubtedly, every effort is made for the safe delivery of a child with minimal pain and suffering. Many countries have reviewed and updated their protocols and guidelines for the management of analgesia after CD. However, the choices of analgesic modalities chosen by physicians in ERRH do not, in many cases, meet the standards of pain management practices. The current practices are mostly old, outdated, and often inconsistent. Although many studies have demonstrated sufficient evidence of the benefits of preventive analgesia for CD (11–13), in this study, only 2% of participants benefited from preventive analgesia. Multi-modal analgesia is the recommended modality for pain management (14, 15). However, this study revealed that despite the availability of analgesics and skills, intra-operatively, only a single class of drug, either injectable Paracetamol or Diclofenac sodium, was administered. Another technique that our hospital can easily employ is the addition of a low dose of intrathecal morphine. The addition of intrathecal morphine has actually shown promising results, and it has been widely used worldwide (16, 17). The complication rate, which most of us fear, is negligible with a dose less than 300 mcg (18). Other alternative approaches could include infiltration of local anesthetic around the incision line and a transverses abdominis plain block (8, 19). These two techniques were not employed to any of the participants of this study. In our hospital, the preferred analgesic for immediate post-operative period of CD was an intramuscular injection of Diclofenac Sodium (63%), which was when the patient complained of pain. Elsewhere, the medication timing as-and-when mode is less advocated because it does not provide continuous pain control, in addition to the patient having to endure additional pain from the intramuscular injection. This was a suboptimal modality of pain management after CD, especially when we had other more effective analgesics in the hospital.

The average length of oral analgesic prescribed for home use was less than 4 days, and patients experienced an average pain duration of 2 weeks. The study also revealed that close to 1 in 10 people were sent home without any oral analgesics, which was unethical.

This retrospective review clearly demonstrated that the management of pain after CDs was inadequate, despite the availability of resources and skills in the hospital. A multimodal analgesia approach could be used for patients. This study advocates a comprehensive pain protocol for CDs in ERRH. This study had a few limitations. This was a single-center study. The findings may not represent patients from other healthcare facilities. The study included only 107 patients, which may be considered a small sample size. However, using a simple randomization technique, the authors included all CDs performed during the study period. As a strength of the study, this may be the first study conducted in Bhutan reviewing the existing management of pain during CD.

Our study revealed that, despite the availability of resources and skills, pain management after CD was inadequate. Initiating a multimodal analgesia approach at ERRH would improve the quality of pain care for CDs.

Cesarean Delivery

ERRH

Eastern Regional Referral Hospital

JCAHO

Joint Commission on Accreditation of Healthcare Organizations

U.S.A.

United States of America

U.K.

United Kingdom

NSAIDs

Non-steroidal anti-inflammatory drugs

Ethical approval and consent to participate

For this survey, ethical approval was given via approval letter number Ref. No. REBH/Approval/2019/005 dated January 11, 2019 from the Research Ethics Board for Health, Ministry of Health, Royal Kingdom of Bhutan. Informed consent was obtained from all research participants

Consent for publication

Not applicable

Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author at [email protected] opn reasonable request.

Competing interest

No conflict of interest

Funding

No funding was needed for this research

Authors’ contributions

Tashi Wangchuk conceived the study design, and collected and analyzed the data. Ugyen Tshering collaborated in the study design, data collection and writing of the manuscript. We both approved the final manuscript for submission.

Acknowledgement

I would like to sincerely thank Dr. David Wright for helping us write the manuscript. Mr. Thinley Wangdi for helping us with the data analysis and interpretation.

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No competing interests reported.

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Editorial decision: Revision requested
31 Jul, 2024
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Submission checks completed at journal
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You are reading this latest preprint version

Can we improve the existing management of pain after cesarean delivery at Eastern Regional Referral Hospital? A retrospective survey

Status:

Version 1

Abstract

Background

Methods

Results

Conclusions

Figures

Background

Methods

Flow chart showing the recruitment process for patients in the study

Results

Physician’s Choice of Injectable Analgesic Used at the Ward for Immediate Post-operative Period after CD

Physician’s Choice of Oral Analgesic Used at Home for Post-operative Pain After CD

Discussions

Conclusion

Abbreviations

Declarations

References

Additional Declarations

Status:

Version 1